Charting Bloopers - page 63

Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill: "Patient vehemently denies any auditory, tactile, or old factory... Read More

  1. by   determined2banurse
    I read in a chart once, "Apply sensicare cream to open areas on scrotum and pennies."
    Another frequent entry I see in charts is, " Good pericare rendered." I always think to myself so you give bad pericare sometimes!
  2. by   AnthonyD
    In a post-code progress note by a cardiologist. "The etiology of patient's breast appears to be hypoxic in nature."

    Ummm... I think he meant "arrest." Freudian slip ya think??
  3. by   kittyvenven
    Quote from km rn
    As we were reviewing a chart on the Alzheimer's unit - this notation stood out:
    "resident very agitated - yelling profound statements" Profane yes - profound no ..I doubt he was yelling "To be or not to be....that is the question...."
    I'm dying!! Hahahahaha!!
  4. by   AcuteHD
    ER report stated "discussed plan of care with passerby" I hope that was an autocorrect error.
  5. by   AnthonyD
    Not so much a blooper, but a very bad order. Nursing free-text order from a PA... "Please remind patient not to drink from his urinal."

    You can't make this stuff up.
  6. by   AcuteHD
    "Patient visible"

    Inadvertent mashup of "patient alert" and "access visible"
  7. by   cardiacfreak
    Admitting diagnosis on patients face sheet: Unstable Vagina.

    Should have been Unstable Angina.
  8. by   AcuteHD
    Quote from cardiacfreak
    Admitting diagnosis on patients face sheet: Unstable Vagina.

    Should have been Unstable Angina.
    Maybe it was a more clinical term for "****** be Crazy"
  9. by   nursecathi
    More and more on H&P's, even on elderly ladies , we're talking 80's & 90's!
    Not currently breastfeeding. Not a blooper. Must actually be part of the docs new charting process!
  10. by   MaleICURN
    Pt. intubated, on vent.
    Condition fair.
    Plan of care discussed with patient, who verbalizes understanding
  11. by   brillohead
    Many of our doctors use a speech-to-text program for their progress notes.
    Many of our doctors are foreign-born, with the accents that come from not speaking English as one's native tongue.
    Labetalol is not a word that speech-to-text programs recognize.

    "Reduce libido to 200 two times per day."

    Four hundred orgasms a day... someone's gonna need a LOT of K-Y!!!!
  12. by   T-Bird78
    One of my doctors types really fast as she's verbally explaining the discharge instructions. I can't tell you how many times she's said to "sue nasal spray". I keep telling her legal action is not necessary to relieve congestion!

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